Laparoscopic hysterectomy with bilateral salpingo-oophorectomy (BSO) is a common gynecologic procedure performed for conditions such as uterine fibroids, adenomyosis, endometriosis, abnormal uterine bleeding, adnexal masses, and malignancies. In postmenopausal women or when indicated, removal of the ovaries and fallopian tubes reduces the risk of ovarian pathology and hormonally driven gynecologic diseases.

The laparoscopic approach offers minimally invasive benefits including smaller incisions, less postoperative pain, shorter hospital stay, and faster recovery. A critical step in laparoscopic hysterectomy is vaginal vault closure, which can be technically challenging. The Weston knot is a reliable technique for intracorporeal suturing, providing secure, tension-free closure of the vaginal cuff and reducing the risk of dehiscence and vault prolapse.

Indications

Laparoscopic hysterectomy with BSO and vault closure is indicated in:

Benign uterine conditions such as fibroids, adenomyosis, and recurrent endometriosis.

Postmenopausal women at risk for ovarian pathology.

Premalignant or malignant lesions requiring removal of uterus and adnexa.

Patients requiring secure vaginal vault closure to prevent postoperative complications.

Preoperative Evaluation

Clinical Assessment:

Detailed gynecologic history including menstrual history, parity, prior surgeries, and symptoms.

Pelvic examination to assess uterine size, mobility, and vaginal anatomy.

Imaging:

Pelvic ultrasound or MRI to evaluate uterine and adnexal pathology.

CT scan if malignancy is suspected.

Laboratory Investigations:

Complete blood count, coagulation profile, renal and liver function tests.

Preoperative tumor markers if malignancy is suspected.

Patient Counseling:

Discuss the procedure, risks, and benefits.

Explain potential complications: bleeding, infection, ureteral or bladder injury, vault dehiscence, and adhesion formation.

Anesthesia and Patient Positioning

General anesthesia with endotracheal intubation is required.

Patient is placed in dorsal lithotomy position, with arms tucked.

Trendelenburg tilt (15–30 degrees) to allow bowel displacement and optimal pelvic visualization.

Foley catheter insertion to decompress the bladder during surgery.

Port Placement

Standard laparoscopic port configuration:

Umbilical port (10–12 mm): Camera port.

Two lateral 5 mm working ports: For instruments and dissection.

Optional suprapubic port (5 mm): For uterine manipulation or retraction.

Port placement may be modified based on uterine size, prior surgeries, or adhesions.

Surgical Steps
Diagnostic Laparoscopy

Survey of abdominal and pelvic cavity for adhesions, endometriosis, or other pathology.

Adhesiolysis performed if necessary to ensure safe access to uterus and adnexa.

Laparoscopic Hysterectomy

Round ligaments are coagulated and transected.

Broad ligaments opened, ureters identified and protected.

Uterine arteries ligated at their origin for hemostasis.

Colpotomy performed around the cervix to mobilize the uterus for removal.

Bilateral Salpingo-Oophorectomy (BSO)

Fallopian tubes and ovaries are mobilized.

Ovarian vessels ligated using bipolar cautery or advanced energy devices.

Adnexa removed along with the uterus or separately depending on anatomy.

Vault Closure Using Weston Knot

The Weston knot is an intracorporeal knot-tying technique providing secure, tension-free closure.

Absorbable sutures (e.g., polydioxanone) are used for vaginal cuff closure.

Sutures are placed along the vaginal mucosa and pelvic fascia to ensure adequate hemostasis and reinforcement of the cuff.

Knot is tied laparoscopically using the Weston technique to maintain uniform tension and prevent slippage.

Ensures durable closure, minimizing risks of vault prolapse, dehiscence, or infection.

Specimen Retrieval

Uterus and adnexa removed via the vaginal route if feasible or morcellated within an endoscopic bag for large specimens.

Ensure no tissue fragments remain in the peritoneal cavity to prevent adhesion formation.

Postoperative Care

Early ambulation and resumption of oral intake.

Pain management primarily with NSAIDs; opioids if needed.

Foley catheter usually removed within 24 hours.

Monitor for complications: bleeding, infection, urinary retention, or vault issues.

Most patients discharged within 24–48 hours.

Avoid heavy lifting and sexual activity for 6–8 weeks.

Advantages

Minimally invasive: Reduced pain, smaller incisions, faster recovery.

Safe adnexal removal: BSO reduces risk of ovarian pathology in indicated patients.

Secure vault closure: Weston knot provides uniform tension and prevents dehiscence.

Reduced adhesion formation and better cosmetic results.

Enhanced visualization: Ability to inspect pelvic organs and manage adhesions.

Complications

Intraoperative: Bleeding, ureteral or bladder injury, bowel injury.

Postoperative: Vaginal cuff dehiscence, infection, urinary retention, hematoma, or adhesion formation.

Prevention: Meticulous dissection, proper suture technique, and careful knot placement using the Weston method.

Conclusion

Laparoscopic hysterectomy with bilateral salpingo-oophorectomy and vault closure using the Weston knot is a safe, effective, and minimally invasive approach for managing uterine pathology in postmenopausal and high-risk women.

By combining careful laparoscopic dissection, adnexal removal, and secure intracorporeal knotting, this technique ensures durable vaginal vault closure, minimal postoperative complications, and rapid recovery, representing a modern standard in advanced gynecologic surgery.